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Key Concepts

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  • Metastatic disease to the lung is the second-most common pulmonary malignancy, affecting 20 to 54 percent of patients with cancer. A subset of patients with metastatic disease present with disease confined to the lung. Complete resection of this pulmonary burden of disease can result in 5-year survival rates as high as 40 to 50 percent.

  • Pulmonary metastases are typically found on surveillance imaging. Very rarely are patients symptomatic with cough, pain, hemoptysis, or dyspnea.

  • Helical, thin-sliced computed tomography is the gold standard for detecting pulmonary metastases. Pulmonary nodules as small as 3 mm can be detected with a sensitivity as high as 75 percent.

  • Treatment options for secondary pulmonary malignancies include systemic chemotherapy, isolated lung perfusion or suffusion, radiofrequency ablation, stereotactic body radiation therapy, and surgical resection.

    • Isolated lung perfusion (ILuP) and suffusion are investigational and should be restricted to institutions with active research protocols.

    • The application of radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT) is limited by the size and location of the nodule. These modalities are typically reserved for patients who are poor operative candidates or who refuse surgery.

    • Pulmonary metastasectomy is the treatment of choice for patients with metastatic colon cancer, renal cell carcinoma, sarcoma, melanoma, and nonseminomatous germ cell tumor. Surgery should also be considered for select patients with metastatic breast and head and neck cancer.

  • Patients considered for pulmonary metastasectomy should meet the following criteria:

    • Primary site of disease is controlled or controllable.

    • Absence of extrathoracic metastases (or, in cases of oligometastases, extrathoracic sites of metastases are controlled or controllable).

    • The patient has the pulmonary reserve to tolerate the appropriate parenchymal loss for a complete resection.

    • Mediastinal and intrathoracic lymphadenectomy is advocated.

  • Pulmonary metastasectomy is associated with the following survival rates:

    • Colorectal cancer 40 to 68 percent (5 years), renal cell carcinoma 47 to 74 percent (5 years), sarcoma 40 percent (5 years), melanoma 22 to 27 percent (5 years), and nonseminomatous germ cell tumor (NSCGT) 74 to 94 percent (5 years)

    • Pancreatic adenocarcinoma 40 percent (2 years), hepatocellular carcinoma 41 percent (5 years), breast carcinoma 35 to 80 percent (5 years), and head and neck squamous cell carcinoma 26 to 50 percent (5 years)

    • Disease-free interval, number of pulmonary metastases, and completeness of resection are significant predictors of long-term survival.

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Introduction

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Pulmonary metastases are defined as secondary malignant tumors of the lung parenchyma or pleura. Originating from an entirely separate organ, metastatic disease to the lung is the second-most common pulmonary malignancy. Autopsy studies have demonstrated that 20 to 54 percent of patients who die with a diagnosis of cancer also have pulmonary metastases. A subset of these patients have metastases limited only to the lung. In their study of 162 sarcoma patients, Huth and Eilber reported that of the patients with recurrent disease, 88 percent had pulmonary metastases, with the lung being the sole site of disease in 72 percent.1 Similarly, Billingsley and associates ...

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